Provider Demographics
NPI:1801858733
Name:TAJ, AYESHA M (DO)
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:M
Last Name:TAJ
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Gender:F
Credentials:DO
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Mailing Address - Street 1:1749 IMAN RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2229
Mailing Address - Country:US
Mailing Address - Phone:734-255-7021
Mailing Address - Fax:
Practice Address - Street 1:1600 S CANTON CENTER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1992
Practice Address - Country:US
Practice Address - Phone:734-398-8675
Practice Address - Fax:734-398-8670
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MI51010136982080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH66725Medicare UPIN